Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City: Zip Code Home Phone: Cell Phone: Date of Birth: Sex (M / F): Marital Status: S M D W Social Security #: Driver s License #: Emergency Contact Name: Phone: Relationship to Patient: Employer: City: Phone: Who Referred You? Insurance Information: Primary Insurance Company: Address: Subscriber Name: Relation to Insured: DOB / / ID#: Group #: Secondary Insurance Company: Address: Subscriber Name: Relation to Insured: DOB / / ID#: Group#: I, THE UNDERSIGNED, AUTHORIZE PAYMENT BY THE ABOVE NOTED INSURANCE COMPANY(S) BE MADE DIRECTED TO CORINNA R. MOSHER, MD A MEDICAL CORPORATION FOR ALL BENEFITS, IF ANY, OTHERWISE PAYABLE TO ME FOR ALL SERVICES RENDERED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES NOT COVERED BY SAID INSURANCE. INCLUDING DEDUCTIBLE AND COPAYMENTS. I HEREBY AUTHORIZE THE RELEASE OF ALL INFORMATION NECESSARY TO SECURE PAYMENT OF SAID BENEFITS. I FURTHER AGREE IN THE EVENT OF NONPAYMENT OF ANY AMOUNTS DUE BY ME, TO BEAR THE COST OF COLLECTION, AND/OR COURT COST AND REASONABLE LEGAL FEES SHOULD THIS BE REQUIRED. Signature: Date: 1
Corinna Mosher, M.D. A Medical Corporation Health Questionnaire What is the reason for your visit? When was your last physical exam? Past Medical History Please list past medical problems: (Such as an illness, operation, or hospital stay) 1. Date: 2. Date: 3. Date: 4. Date: 5. 6. Date: Date: 7. Date: Please list your current medications: (such as prescriptions, herbal supplements, & over the counter meds) Medicine Dosage How often (such as daily, twice daily, etc.) 1. 2. 3. 4. 5. 6. 2
Do you have any allergies to medications? Yes No Medicine Reaction (rash, shortness of breath, etc.) Date or Age 1. 2. 3. When was your last papsmear? Have you had an abnormal papsmear? When was your last mammogram? Have you had an abnormal mammogram? Have you had a breast biopsy? Number of pregnancies: Number of births: Miscarriages/Abortions: What was your age during your first pregnancy: Last menstrual period: Average days of your period: Age at menopause: Age of first period: Have you ever used hormone replacement therapy? When was your last bone density test? What were the results? Have you been screened for colon cancer? (Flexible Sigmoidoscopy or Colonoscopy) When was the test and what were the results? When was your last prostate exam or PSA test? Any abnormal result? When was your last cholesterol test? Results? When was your last EKG or cardiac test? Results? When was your last Tetanus Vaccine: Influenza Vaccine: Pneumonia Vaccine: Hepatitis B series: Hepatitis A series: Family History Please list all genetically related family members: Relative Age Living/Deceased Major Medical Illness/Cause of Death 1. Mother L / D 2. Father L / D 3. Brother/Sister L / D 4. Brother/Sister L / D 5. Brother/Sister L / D 6. Brother/Sister L / D 7. Brother/Sister L / D 3
8. Father s Mother L / D 9. Father s Father L / D 10. Mother s Mother L / D 11. Mother s Father L / D Social History Please list the name, age, sex, and any major medical illness of your children: 1. 2. 3. 4. 5. What is your occupation? What is your religion? Have you ever smoked cigarettes? Yes No How many packs per a day? Have you quit, if so when? How many total years did you smoke? How much alcohol do you typically drink? What type of alcohol do you drink? Beer Wine Liquor Has anyone ever urged you to quit drinking or to get counseling to quit? Yes No Do you use any other drugs? (marijuana, cocaine, heroin, ecstasy, GHB, codeine, valium, speed, glue, etc.) No Yes (please list): Do you take a calcium supplement? Do you always wear a seatbelt? Yes No Do you have a gun at home? Yes No How many days per a week do you exercise at least 30 minutes? Do you feel safe at home? Yes No 4
Review of Systems (Please circle any symptoms you have experienced in the past six months) 1. General: Fevers, Chills, Night sweats, Fatigue, Weight loss, Weight gain 2. Head: Dizziness, Headaches (frequent or unusual), Head injury 3. Eyes: Change in vision, Double vision, Eye Pain, Redness, Excessive tearing, Glaucoma 4. Ears: Ringing, Hearing loss, Hearing aid, Discharge, Pain, Bleeding 5. Nose: Nosebleeds, Infections, Discharge, Stuffiness, Itching, Snoring, Sores 6. Mouth and Throat: Dry Mouth, Frequent sore throat, Hoarseness, Postnasal Drip, Bleeding gums, Tooth pain 7. Neck: Lumps, Pain on movement, swollen glands, thyroid trouble 8. Chest: Cough, Coughing up blood or sputum, Shortness of Breath, Wheeze 9. Cardiac: Chest Pain, Chest Pressure, Palpitations, Waking up in the Night Short of Breath, Shortness of Breath with minimal exertion 10. Vascular: Pain in the Legs, Calves, Thighs or Hips While Walking, Leg Swelling, Loss of Hair on Legs, Ulcers 11. Breasts: Lumps, Nipple Discharge, Pain, Tenderness, Skin Changes 12. Gastrointestinal: Change in Appetite, Nausea, Vomiting, Heartburn, Constipation, Diarrhea, Black Stools, Blood in your Stool, Trouble Swallowing, Abdominal Pain 13. Urinary: Urinary Frequency, Urinary Urgency, Difficulty in Starting Urine Stream, Incontinence of Urine, Excessive Urination, Pain on Urination, Blood in Urine, Number of times you urinate at Night? 14. Male: Hernias, Penile Discharge, Impotence, Testicular Pain, Testicular Mass, Sores, Difficulty getting or maintaining an Erection, Sexually Transmitted Diseases 15. Female: Vaginal Lesions, Itching, Sores, Abnormal Discharge, Hernia, Sexually transmitted diseases, Spotting between periods, Spotting after menopause, Decreased Sex Drive 16. Musculoskeletal: Muscle Pain, Joint Pain, Stiffness, Arthritis, Back Pain 17. Neurologic: Fainting, Seizures, Blackouts, Weakness, Paralysis, Numbness, Strokes, Tremors, Loss of consciousness, speech disorder 18. Mood: Nervousness, Anxiety, Depression, Suicidal Thoughts, Insomnia, Feelings of hopelessness 5